DC Cancer Plan |
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Statement of Support
for As the
directors of the
As much as the cancer centers and cancer-related organizations in the District work to reduce the number of people being diagnosed with, suffering from, and dying from cancer, we realize that much more is needed. The Cancer Plan before you provides a blueprint for the next steps to be taken if we are to make meaningful progress toward reducing suffering and death from cancer. We must work together if we are to reduce the burden of cancer in our city. To that end, the DC Cancer Coalition, a broad partnership of public and private institutions, organizations, and advocates has developed a comprehensive, coordinated plan with specific strategies to have a greater impact on cancer in the District. Our institutions are committed to work collaboratively together and with the cancer community in implementing the Plan, and we invite all other concerned citizens and organizations to join us. Please become familiar with the Plan. Talk with your colleagues.
Then identify how your institution, agency, or organization can use the Plan as
a guide for your own activities and consider what role you can play in
implementing strategies for the greater good of the citizens of the
Lucile Adams-Campbell, PhD Steven
Patierno, PhD
Lawrence S. Lessin, MD Richard G.
Pestell, MD, PhD
Executive Summary: Creating
the District’s First Cancer Plan
In
2001, because the
The
Coalition is a partnership of medical centers, nonprofit organizations,
academic and research institutions, community groups, advocates, professional organizations,
and others. We have worked together for four years to produce the District’s
first Cancer Plan—an analysis of the present environment, a blueprint to reduce
the number of new cases of cancer and the number of cancer-caused deaths and to
improve the quality of life for cancer survivors in the nation’s capital.
As
you will see, the need is urgent.
Cancer
in the District: Portrait of Inequity
Our
city of 560,178 residents—the nation’s capital—has the highest cancer mortality
rate per population in the
These
high rates exist despite having four cancer centers, a total of 11 hospitals,
and an abundance of excellent cancer care services. But many of these services
are neither accessible nor affordable for many of DC’s citizens—the poor and
medically underserved (uninsured and underinsured), most of whom are Black or
Hispanic. About 58% of the District’s population is Black, 27% is
White and 3% Asian. About 10% of the population is of Hispanic origin (some
self-identifying as White, and some as Black). Another 2% describe themselves
as “two or more races or other.” [Thomson Medstat©2004] The Hispanic population
is the city’s fastest-growing and includes many of the poorest residents.
Hispanic residents are the least likely to have health insurance of any kind.
Key
factors influencing the high rates of cancer incidence and mortality include
• Lack of medical homes. Many of the District’s residents—about 300,000—live in a “Health Professional
Shortage Area (HPSA).” This includes many of the working poor. These residents
lack what is called a “medical home,” a primary care provider who knows their
health history and is a reliable source of routine medical care. The single
largest determining factor in the use of cancer services, from prevention
through treatment and follow-up, is having a primary care physician who makes
recommendations and provides assistance in navigating the health care system.
The DC Primary Care Association (DCPCA) links this lack of adequate primary
care to poorer health outcomes, higher health care costs, and overused, overcrowded emergency rooms.
“Because people can’t find a doctor,” • Screening
difficulties. Deaths from breast, cervical, colorectal, and
prostate cancer can be avoided or decreased through screening procedures.
However, facilities for cancer screening are few and far between in the
District’s poorer neighborhoods. Most screening resources are located north of
the
• Additionally, the
District underfunds • The
health care labyrinth. In addition to its many hospitals and
medical centers, the District prides itself on having many public and private
health care clinics. However, the clinics are only loosely linked to each other
and to other parts of the health care system. It can take people with symptoms
a long time to get a clinic appointment, and a patient who does manage to get
screened and receives a screening result indicating possible cancer may not get
appropriate • It can be very
difficult for any patient—rich or poor, highly educated or uneducated— • Information
deficit. The DC Cancer • Fragmented
health insurance system. The DC HealthCare Alliance, in
partnership with the DC Department of Health, private and nonprofit health
clinics, offers low-income residents access to an array of health care
services. Because the
• It should be noted
that, unlike most states, the
The bottom line is that many of the
District’s neediest residents cannot or do not take advantage of available
cancer care in the District. They struggle to navigate the convoluted health
care system, the programs designed to provide care often fail to do so, there
is no substantive public health structure—and as a result people are dying of
cancer at high rates, despite living near highly sophisticated cancer care
facilities.
Plan preparation and components The DC Cancer Coalition workgroups (including physicians, public health experts, community leaders and others) have developed specific research-based chapters of the Plan. In each chapter, we assess the cancer burden, address current resources, identify gaps in care, and set forth prioritized recommendations that we believe will set the District and the health care community on course to correct the problems presented.
What Must Be Done: Implementation The next step in addressing cancer control and prevention is
to use the Cancer Plan to move the District forward. We understand that
bringing the Cancer Plan to life is the work of years, and that with individual
and collaborative actions must come ongoing evaluation and mid-course
corrections as needed to respond to the changing Some of the work ahead will require examining public policy that affects cancer in DC. Other priorities demand new avenues of collaboration among the city’s health care providers, and securing the funding necessary to make collaboration possible and effective. These tasks are formidable, but the Coalition’s members are committed to doing everything in our power to relieve DC’s heavy burden of cancer incidence and mortality. Behind the statistics is great human suffering, and that suffering must be alleviated. Almost every part of cancer care as it relates to the
medically underserved majority of residents in the
Goals and Objectives
OVERARCHING GOAL AND PRIORITIES OF OVERALL GOAL: Reduce cancer incidence and mortality, reduce racial and ethnic disparities in cancer treatment, and improve the quality of life of cancer survivors by Improving access to care • Merge the DC Health Care
• Secure sufficient funding for the combined
• Ensure every resident has a “medical home” for primary care • Provide patient navigation for cancer screening and treatment • Coordinate cancer services by linking clinics and hospitals • Improve cancer-related transportation services • Improve cancer patients’ access to clinical trials Increasing rates of screening, particularly for breast, cervical, prostate and colorectal cancers, and providing all necessary follow-up cancer care Increasing
public awareness of healthy behaviors that prevent cancer
• Reduce tobacco use • Reduce obesity • Increase regular physical activity • Eat healthy food and avoid overeating Advocating with the City government on issues and funding relating to cancer Educating
health care providers about
• Early detection of cancers • Pediatric cancers • Rehabilitation • Palliative and end-of-life care Improving
the collection and use of DC data about cancer
• Improve quantity and quality of data collected about the Hispanic population Educating survivors and caregivers about resources and
follow-up care
Increasing awareness of and availability of palliative care
and end-of-life care
CHAPTER GOALS AND OBJECTIVES ACCESS TO CARE
GOAL: To improve access to primary and cancer care for DC residents. Objectives:
1) Create a coordinated patient navigation system by 2008. 2) Establish
affiliation agreements between the community health centers, hospitals, and
health 3) Improve access to public transportation for cancer patients by 2010. 4) Increase
the participation of eligible minority residents in cancer-related clinical
trials by 15% 5) Educate consumers about access to cancer screening, care, and other services by 2010.
PREVENTION
GOAL: Reverse the trend toward obesity and overweight by
increasing physical activity and the consumption of fruits and vegetables and
by reducing Objectives:
1) Reduce the prevalence rate of obesity among DC adults to 15% by 2010. 2) Reduce the prevalence of overweight adults to 40% by 2010. 3) Reduce the prevalence rate of overweight and obese children to 5% by 2010. 4) Increase to 60% the prevalence rate of adults who engage in regular, moderate physical activity for at least 30 minutes a day at least five days a week by 2010. 5) Increase to 40% the prevalence rate of high school students who engage in moderate physical activity 30 minutes or more, five or more days a week by 2010.
SMOKING-RELATED CANCERS <top> GOAL: Reduce mortality from smoking-related cancers in the
Objectives:
1) Reduce the level of smoking among high school
students from 13% to 10% by the year 2010.
2) Reduce the level of smoking in current Black and Hispanic smokers and those with low levels of education by 25% by the year 2010. 3) Reduce general exposure to secondhand smoke by creating a smoke-free environment in all public places by 2006. 4) Reduce racial disparities in smoking prevalence by 2010. HEAD AND NECK
CANCERS
GOAL 1: Reduce the mortality rate in DC from cancers of the head and neck by 10%. GOAL 2: Reduce the incidence of invasive cancers of the head and neck in DC by 10%. Objective:
Increase to 50% the proportion of head and neck cancers detected at the local stage for both men and women by 2010.
BREAST CANCER
GOAL: Reduce mortality rates from breast cancer in the District by 10%, especially among Black women. Objectives:
1) Reduce the incidence of invasive disease in DC by 10% by 2010. 2) Increase
the number of women aged 50 through 64 who are screened annually by 10% 3) Reduce the proportion of unstaged cases to less than 5% by 2010.
GYNECOLOGIC
CANCERS
GOAL 1: Identify a greater proportion of cervical cancer cases before the cancer has spread beyond the local stage. Objectives:
1) Increase the proportion of women diagnosed at the local stage to 90% by 2010. 2) Increase the rate of Pap screening to 90% (recent
screens) and 97% (ever-screened) in all GOAL 2: Make 50% of women aware that postmenstrual bleeding is
a possible GOAL 3: Increase public awareness of ovarian cancer symptoms. Objectives:
1) Reduce the incidence of late-stage diagnosis by 2010. 2) Improve the amount of accurate staging of ovarian cancer
and reduce the proportion of GOAL 4: Improve the quality of care for underinsured and
uninsured women in the Objective:
1) Increase information and support to DC clinics and providers treating the target population by 2010. COLORECTAL CANCER
GOAL 1: Reduce the mortality rate in DC from colorectal cancer by 10%. GOAL 2: Reduce the incidence of invasive disease in DC by 10%. Objectives:
1) Increase to 50% the proportion of colorectal cancer detected at the local stage for both men and women by 2010. 2) Increase
to 50% the proportion of the adult population that reports having had a fecal
occult
PROSTATE CANCER
GOAL: To reduce the mortality rate from prostate cancer in DC by 10%. Objectives:
1) By the year 2010, increase to 65% the percentage of Black men 45 years or older who are annually screened for prostate cancer. 2) By the year 2010, reduce the proportion of unstaged prostate cancer cases to less than 5%.
PEDIATRIC CANCERS
GOAL: To ensure that all
Objectives:
1) Develop a system for coordinating research and the dissemination of information about diagnosis, clinical trials, treatment, follow-up care and supportive services to health care providers in DC by 2010. 2) Ensure that all DC childhood cancer patients and their families have access to culturally relevant information and services, from diagnosis through survivorship or end-of-life and bereavement services by 2010. 3) Establish a system to ensure that accurate data on incidence, survival, and mortality rates for pediatric cancers are collected and are available for health care providers, researchers, and the public by 2010. PALLIATIVE CARE
GOAL 1: Integrate palliative care into the District’s health care system and increase public understanding of palliative care and its role in cancer care. Objectives:
1) Provide education about palliative care for health care providers and the public by 2010. 2) Promote the development of palliative care programs in health care facilities and community- based settings throughout the District by 2010. 3) Develop innovations and changes in the health care delivery system that promote palliative care services by 2010. GOAL 2: Improve the availability of,
and access to, palliative care services for the underserved and culturally
diverse population of the
Objectives:
1)
Strengthen the health care delivery system, including palliative care for
underserved and diverse populations in
the
2) Target public service messages about palliative care to specific
underserved populations by 2010. CANCER SURVIVORSHIP <top> GOAL: Improve the quality of life for DC cancer survivors. Objectives:
1) Implement a coordinated patient navigation system by 2008. 2) Increase demand-responsive public transportation for low-income cancer survivors by 2007. 3) Assess current resources for survivors and caregivers by 2006. 4) Promulgate clinical practice guidelines for each stage of cancer survivorship, from diagnosis through long-term treatment and end-of-life care by 2007. 5) Establish a database on cancer survivorship by 2008. 6) Educate corporate, academic, and community policymakers and decision-makers about key health care issues for cancer survivors by 2008. 7) Develop a community awareness program for cancer
survivors by 2007. CANCER
REHABILITATION
GOAL: Increase awareness of
cancer rehabilitation services in the
Objectives: 1) Create a
repository of information on cancer rehabilitation services in the
2) Increase awareness and knowledge of fellows in training, oncology physicians, and oncology nurses about cancer rehabilitation and services by 2008. 3) Increase public awareness of cancer rehabilitation and services available by 2009. 4) Develop liaisons among area hospitals and community organizations to conduct research on effective cancer rehabilitation assessment and treatment by 2010.
Introduction:
To address the problem of very high rates of cancer in the
Committed to addressing the District’s very high cancer rates—the highest cancer death rates in the nation—the Coalition is a broad-based partnership, including medical centers, nonprofit organizations, academic and research institutions, community groups, advocates, professional organizations, and others. All have an interest in cancer prevention and control. Our objective has been to develop a comprehensive cancer control plan that could serve as a blueprint for reducing the number of new cancer cases in the District and the number of deaths from cancer. We have followed the CDC’s model of creating “an integrated coordinated approach to reducing cancer incidence, morbidity, and mortality through prevention (primary prevention), early detection (secondary prevention), treatment, rehabilitation, and palliative care.” The Plan is designed to • Identify the strengths and weaknesses of current cancer prevention and control efforts in DC • Identify barriers that hinder prevention and control efforts and offer strategic options for surmounting them • Provide a set of goals and objectives for cancer control based on a review of DC data • Identify strategies for meeting those objectives. Disparities in cancer care in DC: The District is home to an abundance of medical care facilities and providers, but equal access to cancer care services is significantly undermined by the physical location of those providers. Access to cancer screening, treatment, and follow-up care is, in some measure, influenced by where a District resident lives. Geographically, the District is divided into four quadrants: northwest, northeast, southwest, and southeast. Politically, it is divided into eight wards (see Figure 1). Wards 1, 3, and 4 are in the northwest quadrant; Ward 2 straddles northwest and southwest; Ward 5 is mainly in the northeast (and a bit of northwest): Ward 6 is in northeast, southwest, and southeast; Ward 7 is in both northeast and southeast; and Ward 8 is in the southwest and southeast quadrants. Many cancer-related
health care facilities are located in northwest
full-service hospital located beyond the
The inequitable distribution of infrastructure for cancer care in the District is reflected in the city’s cancer incidence and mortality rates. Disparities in access to care and in the quality of care are seen in every aspect of cancer control: screening, early detection, incidence, treatment, quality of care, and survival. Disparity issues are considered in nearly every chapter of the Cancer Plan. We expect implementation of the Plan to facilitate the creation of an effective local infrastructure for reducing these disparities, for reducing high cancer incidence and mortality rates in the District, and for improving the quality of life of cancer survivors—wherever in the city they may live. Ethnicity. As of 2004, DC’s population Income. Although the city’s population is
distributed roughly equally among the eight wards, income distribution is
unequal. A Education. Almost 300,000 Washingtonians—
Developing the Cancer Plan To develop the Plan, the Coalition created Primary focal points. The Plan’s primary focus
was on strategies known to reduce the number of cases of cancer and to reduce
deaths from the disease. Recommendations for cancer screening were based mainly
on those of the American Cancer Society, although recommendations from the
Preventive Services Task Force and other professional organizations were also
reviewed. A secondary focus was to identify resources to assist people with
cancer, including support groups, educational programming, and other community
opportunities. These resources are presented in a separate publication, the Based on data about the burden of cancer and available health
care resources in the Priorities were based on scores of four factors: • The extent of a particular cancer burden • Whether intervention was important • Whether intervention was feasible • Whether intervention would have a measurable impact (that is, reduce incidence and/or mortality rates). The burden of deaths from smoking-related cancers, for
example, is sizable. Effective intervention is feasible, and its impact would
be large and measurable. Similarly, the burden of prostate cancer is the
District is both heavy and inequitable, and effective intervention is solidly
feasible and measurable. Breast cancer interventions are a priority because the
cancer burden is heavy, mammography is For each type (or anatomical site) of cancer, we looked at
risk factors, gaps in and barriers to cancer control, and the best-known The chapters were reviewed for accuracy In the summer 2005, the DC Cancer Coalition held a series of five town hall meetings in neighborhoods around DC to introduce the Plan, to listen to residents’ thoughts and reactions to the Plan and to encourage residents to get involved in fighting cancer in the District. The Department of Health also held a series of Health Disparities Town Halls at which they announced the Plan and invited residents to become involved in implementing the Plan. The Coalition is pleased to present this Plan to the
citizens, community leaders, and city authorities of the
Great therapeutic developments over the past few decades have
led to more effective and less disfiguring cancer treatments. But not every
American has benefited from this In 2004, the number of insured nationally rose to 45.8 million, compared to 45.0 million in 2003 and 39.8 million in 2000. A continuing decline in employer-sponsored plans is a major cause. The percent of working adults (18 to 64) who were uninsured climbed from 18.6% in 2003 to 19.0 percent in 2004, an increase of more than 750,000 people. Nationwide, African Americans (20%) and Hispanics (33%) were much more likely to be uninsured than White, non-Hispanic people (11%). Reducing cancer incidence and mortality
rates in the District of Columbia will require eliminating barriers to primary
and cancer Barriers to care in the District Demographics—insurance coverage, poverty, Lack of health insurance. Whether DC In 2004, the number of insured nationally rose to 45.8
million, compared to 45.0 million in 2003 and 39.8 million in 2000. A continuing
decline in employer-sponsored plans is a Proportionately, more DC
citizens are covered by employer-sponsored insurance than the national average
because of the concentration of federal agencies and offices in the District.
Of DC’s non-elderly adults, 70% have employer- Of those
with no health insurance, 4% are
enrolled in the DC HealthCare Alliance, a public-private partnership
established after DC
Who are the uninsured?
• In 1999, 60% of DC
adults may have
qualified for Medicaid or DC HealthCare • In 1999, 36% of DC adults over age 65 had income that fell below 200% of the federal poverty level, possibly qualifying them for Medicaid. • The number of Medicaid enrollees in DC represented 81% of the eligible population in 2001, according to the Centers for Medicare and Medicaid Services. • Many of the “working poor” are uninsured: 72% of uninsured DC residents are part of family households in which at least one household member works part- or full-time, and 48% of the uninsured have family members who work full-time, year-round. • The largest group of
uninsured adults (29,500) is 30-to-49-year-olds, but another age group, the
19-to-29-year-olds, has the greatest percentage of uninsured. The two groups
with the most uninsured members are Hispanic residents (about 13,800 • Undocumented aliens have no health
insurance. Although they can receive free or low-cost health care at a
community health center, the center will ask them to apply for Medicaid so it
can recover some of its costs. Undocumented residents are reluctant to apply
for a public program because it • In the year 2000, 13%
of DC residents worked for small-business employers, who were less likely to
offer insurance because • Some low-wage earners have to forfeit health insurance benefits because they cannot afford the employee’s share of the premium. • About one-third of
DC’s non-elderly adults went without health insurance for all or part of the
two-year period from 2002 to 2003. Adults with no insurance and those with
Medicaid are more likely than adults with • Residents with some
health insurance may not have coverage for pharmaceuticals,
durable medical equipment, nutritional
supplements, sub-acute care, long-term care, or mental health services.
Medicare • Some adults don’t seek treatment
or care because they can’t afford the cost of co-payments or out-of-pocket
expenses for items that are not covered.
Poverty, race, and socioeconomic status. Race
and ethnicity themselves are not Levels of education and literacy, especially health literacy,
are important aspects of social status that affect health outcomes. The Socioeconomic status is also a factor. Socioeconomic status also appears to affect the quality of care. People from lower socioeconomic groups also have poorer survival rates, possibly because of such factors as inadequate staging evaluation and delays in treatment. Regardless of treatment, cancer patients from lower socioeconomic groups with advanced cancer report less symptom control and less use of palliative and supportive care services (especially hospice) than patients from higher socioeconomic groups. The percentage of uninsured in DC (13%) is lower than the
national average (19%), but the
(12.4%). Although the city’s population is distributed
roughly equally among eight wards, income and relative insurance status are Unfortunately, the poverty gap—the gap
between the wealthy and poor—is as wide in DC as in any other major
The adult populations in DC most likely to be uninsured are poor, male, and Hispanic or Black. The Hispanic population is particularly vulnerable, having the highest uninsured rate, being poorer than non-Hispanic Blacks or Whites, and having worse health indicators than both groups.
Language. Residents of the
Age. Although 77% of all cancers are Gender. Evidence shows that men seek routine preventive medical care less often than women, but research has shown practitioner bias in screening men for cancer more often than women. Culture. People immigrating to the District
from other countries bring with them a host of customs, attitudes, and health
care practices that can affect their health care here. Poor immigrants,
especially when confronted with a complex health care system managed in a
language different from their own, may simply avoid or minimize contact with it
except in emergencies, and rely on practices they know from their own cultures.
Similarly, the pressure of urgent daily priorities such as food,
employment, transportation, education,
housing, and safety may mean that cancer screening for early detection becomes
a Transportation. Barriers to screening or
cancer care can be as basic as not Barriers to care from primary care and cancer care providers Problems among primary care providers and oncologists may limit some patients’ access to good health care. Physician competence, knowledge, • The provider’s biases and beliefs about screening and treatment effectiveness • Insufficient knowledge, training, or skill (performing a clinical breast exam, for example) • A dearth of culturally sensitive resources • Forgetfulness and lack of time • Concern about the
patient’s other acute • Conflicting screening
guidelines from • Concerns about patient acceptance • No chance of reimbursement • Logistical or organizational barriers • Prejudices based on
age, race, gender, • Inadequate communication skills. Too few health care professionals and services in low-income
neighborhoods. As of 2001, DC had the highest
physician-to-population ratio of any state, but most of those physicians do not work in low-income neighborhoods
(see Table 4 for location of clinics by ward). According to the Bureau of
Primary Care of the U.S. Department of Health and Human Services, 300,825 DC
residents (52% of the total population) live in federally designated primary
care Health Professional Shortage Areas (HPSAs) and 173,228 (30%) live in
federally designated Medically Underserved Areas (MUAs). Areas designated HPSA
and MUA tend to include many poor households and homes of racial and ethnic
minorities.
A lack of “medical homes.” Many of the 300,000
District residents identified as living Too few specialists serving poor neighborhoods. The DC HealthCare Alliance has difficulty enrolling and maintaining oncologists and other specialists, who feel the insurer’s reimbursement rates are too low and slow. Problems intrinsic to the local health When
DC prides itself on its many private and public community health centers that provide excellent primary care. The weakness of the community health centers is that they are only loosely linked to each other and to other parts of the health care system for services such as diagnostic follow-up, cancer treatment, behavioral health, transportation, counseling, pharmacy or hospital services. As a default, patients may use hospital emergency services that are more expensive and more traumatizing to the patients.
On the other hand,
community health centers often have difficulty retrieving reports from Even an educated person, astute about health care, can have
trouble navigating the labyrinth of health care resources, regulations, and Professional or lay “patient navigators” can help a patient through the system if a competent family member or friend cannot. Especially with medically underserved and vulnerable populations, patient navigation has been effective in improving access to good care. A few community health centers and DC’s Project WISH successfully use patient navigators. But the need for patient navigation far outweighs current resources. Reimbursement and funding problems. After
But the
• Because the city
chronically underfunds the
• It added no additional
community health centers or physicians to DC’s medical • It has had difficulty enrolling specialists in its network of physicians because of low and slow reimbursements. • It does not reimburse physicians who serve DC HealthCare Alliance or Medicaid patients in the emergency room. • It reimburses
hospitals and physicians slowly and at far below the actual cost of care (15 cents
on the dollar), so hospitals have to absorb millions of dollars in
uncompensated care each year. Providers have little incentive Another support service for District residents is the Archdiocesan Health Care Network, whose mission is to connect uninsured patients seen in their clinics with appropriate specialists and tests. This network has several hundred physician-specialist volunteers who will see patients from the clinics for workups and in some instances will provide surgery and follow-up care. Regional resources and clinical trials. DC is
fortunate in having eleven hospitals that hospitals. The cancer programs of eight
hospitals are approved by the Commission
on Cancer of the
Community health centers. Half of the community health centers in DC offer early morning hours, 38% offer evening hours, and one-third offer Saturday hours. Ward 1 has the most community health centers; Ward 4 has none. In the District, there are • Three federally qualified health centers (FQHCs) with 28 sites • Three hospital-sponsored health centers with 14 sites • Eleven private, nonprofit centers with 12 sites • Twelve uncategorized clinics. In the fall of 2003 the DC Primary Care
Limited screening programs and Problems filling prescriptions. Two Progress The Department of Health reports that a Meanwhile, the DC Primary Care Association, with significant
support from the DC
Goals, Objectives, and
Strategies
GOAL: To improve access to primary
and cancer care for DC residents.
Objectives and strategies: 1) Create a coordinated patient navigation system by 2008. • Seek funding for coordinated patient navigation in hospitals and community health centers. • Develop a coordinated patient navigation system. 2)
Establish affiliation agreements between the community health centers,
hospitals, • Facilitate negotiation of these affiliation agreements. 3) Improve access to public transportation for cancer patients by 2010. • Work with the Washington Metropolitan Area Transit Authority (WMATA) to expand
its 4)
Increase the participation of eligible minority residents in cancer-related
clinical • Advocate for legislation requiring insurers to cover routine patient costs for clinical trials. • Update health care providers on clinical trials and encourage patient referrals. • Launch an awareness and recruitment campaign focused on racial and ethnic populations, particularly Blacks and Hispanics. 5) Educate consumers about access to
cancer screening, care, and other services
References Adams-Campbell LL et al.
Enrollment of African Americans Onto Clinical Treatment Trials: Study Design
Barriers. Journal of Clinical
Oncology. 2004;22: 730-734.
Cohn, D’Vera. “DC Gap in
Wealth Growing,” in Washington Post, July 22, 2004
<www.washingtonpost.com/wp-dyn/articles/A4052-2004Jul21.html>.
DC Office of Planning.
2000 Population by Age by Ward. Available at:< <www.planning.dc.gov/planning/cwp>.
Accessed January 7, 2005.
DC Primary Care
Association. Primary Care Safety Net: Health Care Services for the Medically
Vulnerable in the
Families USA. Who’s
Uninsured in the
Kaiser Family Foundation,
The Henry J. Coverage and Access of Adults 18-64 in the
Lurie N, Stoto M. Health
Insurance Status in the
Mandelblatt JS, Yabroff
KR, Kerner JF. Equitable Access to Cancer Services. Cancer 1999;86:2378-2390.
Rivera P, Billington M.
Curanderas Offer Traditional Help.
Wilson
JF. The Crucial Link Between Literacy and Health. Annuals of Internal Medicine 2003; 139(10): 875.
Cancer Prevention
Facts in brief
• Smoking and overconsumption of alcohol (especially combined) • Overexposure to ultraviolet light (through sunlight or tanning salons) • Overconsumption of red meat, especially when charred • Overconsumption of fat and sugar • Consumption of food cooked with harmful fats. • Insufficient consumption of fruits, vegetables, and whole grains—rich in vitamins, antioxidants, and minerals that may help slow or prevent the development of cancers. • Too little physical activity.
Cancer has now surpassed heart disease as the nation’s number
one killer for persons age 85 or younger. Coronary heart disease
American health has declined as Americans have shifted
increasingly to a diet of foods high in fat, sugar, and refined grains—the
staples Current dietary recommendations include minimal fats and red
meat and plenty of fruits, vegetables, and whole grains. Fruits and The type of fat
consumed matters to general health, as well. Authorities recommend that foods
be prepared with such fats as olive oil, canola oil, and safflower oil.
Surveys show that only 23% of adults and 21% of the young
consume the minimum five daily servings of fruits and vegetables recommended by
the National Cancer Institute. In
Overweight as a risk factor Lifelong eating behaviors develop early in childhood.
According to surveys conducted by the Centers for Disease Control, many DC
teens aged 12 to 17 are at risk or already overweight. Rates are especially
high among Hispanic and Black teens. Improving the Concern is growing about obesity’s effect on cancer, heart disease, and stroke. Obesity rates among adults increased 75% between 1991 and 2001. In the last 20 years, the rates have doubled in children and tripled in teens. The prevalence of obesity in men is the same among all racial/ethnic groups, but in women the prevalence is highest among Blacks. More than half of Black women over 40 are obese and 80% are overweight.
The American Cancer Society estimates that obesity accounts
for 14% of all cancers in men and 20% of those in women in the
In the
Obesity trends among Smoking and alcohol In hundreds of studies, smoking has been Alcohol is known to interact with tobacco smoke in causing cancers in the oral cavity, upper respiratory tract, throat, and gastrointestinal tract. Alcohol and smoking have also been associated with second cancers arising in the mouth and throat after a first mouth or throat cancer has been treated. The most effective way to prevent cancers of the mouth and throat is to avoid tobacco and drink minimal amounts of alcohol. Alcohol has also been associated with cancers arising in the large intestine and pancreas, although the evidence is not as strong as with cancers arising in the head and neck.
There is also evidence that alcohol may increase the risk of breast cancer in postmenopausal women. Physical activity Regular physical activity is an important There is a clear relationship between physical Physical activity is also important in cancer treatment and
rehabilitation, helping to The 2001 Shape of the Nation Report issued by the National Association for Sport and Physical Education strongly
recommended physical education for grades K through 6.
Physical education grades are included in the grade point average. No other activity substitutions are allowed. Avoiding overexposure to the sun The most common carcinogen to which people are exposed is
sunlight (especially ultraviolet light). Overexposure to sun has been
associated with all forms of skin cancer, the most common cancer in humans.
Most skin cancers can be treated; only one, melanoma, is difficult to treat
and, when advanced, carries a high death rate. Since 1973 the rate of Chemoprevention Agents designed to prevent cancer or to inhibit growth of
precancerous lesions are under extensive investigation. The National Cancer
Institute, for example, is conducting a
Why well-known preventive measures aren’t common practice Why don’t more people eat healthy diets, get enough exercise,
refrain from smoking and drinking too much alcohol, and generally follow
practices that would reduce the likelihood of cancer and other chronic
illnesses? There are several reasons. First, physicians fail to In some communities, including many parts
Goals, Objectives, and
Strategies
GOAL: Reverse the trend toward
obesity and overweight by increasing physical Objectives: 1) Reduce the prevalence rate of
obesity among DC adults to 15% by 2010.
2) Reduce the prevalence of overweight
adults to 40% by 2010.
3) Reduce the prevalence rate of
overweight and obese children to 5% by 2010.
4) Increase to 60% the prevalence rate
of adults who engage in regular, moderate 5) Increase to 40% the prevalence rate
of high school students who engage in Strategies: • By January 2008,
develop and maintain an intervention clearinghouse that encourages • Develop a community-based
volunteer cadre to counsel families on health education and • Develop culturally appropriate materials and promote prevention activities through community educational forums, the media, the DC government, employers and other vehicles. • Include prevention information in all DC forums that address cancer issues. • Join or supplement the efforts of other local organizations interested in controlling obesity, such as the American Heart Association and American Diabetes Association. • Through the Mayor’s
Council on Physical Fitness, implement school and work-based • Encourage employers to
adopt programs that promote physical activity, such as onsite • Support Board of Education efforts to provide healthy, well-balanced meals to students in grades K-12, and to encourage good life-long eating behaviors. • Decrease the availability and marketing of foods and beverages of low nutritional value in schools and increase the availability of nutritious food products. • Through professional organizations, conduct educational programs so that physicians can promote the benefits of prevention practices to their patients. References Block G, Patterson B,
Subar A. Fruit, vegetables, and cancer prevention: a review of the
epidemiological evidence. Nutr Cancer. 1992;18:129-
Bowman SA, Gortmaker SL,
Ebbeling CB, Pereira MA, Ludwig DS. Effects of fast-food consumption on energy
intake and diet quality among children in a national household survey.
Pediatrics 2004;113:112-118.
Calle E, et al,
Overweight, obesity and mortality form cancer in a prospectively studied cohort
of US adults.
Centers for Disease
Control and Prevention. Trends in Intake of Energy and Macronutrients – United
States 1971-2000. MMWR 2004;53:80-82.
Day GL, Blot WJ, Shore
RE, McLaughlin JK, Austin DF, Greenberg RS, Liff JM, Preston-Martin S, Sarkar
S, Schoenberg JB. Second cancers following oral and pharyngeal cancers: role of
tobacco and alcohol. Journal of the
National Cancer Institute. 1994;86:131-137.
Flegal K, et al.
Prevalence and trends in obesity among us adults, 1999-2000. Journal of the American Medical Association. Heber D. Vegetables,
fruits and phytoestrogens in the prevention of diseases. Journal of Postgraduate Medicine. Lew EA, Garfinkeld L.
Variations in mortality by weight among 750,000 men and women. Journal of Chronic Disease. 1979;32:563-576.
Ogden C, et al.
Prevalence and trends in overweight among
Smith-Warner SA,
Spiegelman D, Yaun SS, van den Brandt PA, Folsom AR, Goldbohm RA, Graham S,
Holmberg L, Howe GR, Marshall JR, Miller AB, Potter JD, Speizer FE, Willett WC,
Wolk A, Hunter DJ. Alcohol and breast cancer in women: a pooled analysis of
cohort studies. Journal of the
American Medical Association. 1998;279:535-540.
Steinmetz KA, Potter JD.
Vegetables, fruit, and cancer. I. Epidemiology. Cancer Causes and Control. 1991;2:325-357.
Thomas DB. Alcohol as a
cause of cancer. Environmental
Health Perspective. 1995;103
(Suppl 8):153-160.
United States Department
of Agriculture, Agricultural Research Service. Food and Nutrient Intakes by
Individuals in the
Smoking-Related Cancers
Facts in brief
• Of the roughly 650 cases of smoking-related
cancers a year in the District, about • The lung cancer
mortality rate for Black males in DC is similar to the Black rate nationally,
but the rate for White males in DC is only 64% of the national rate for White
males. In fact, for both White men and women, DC has the lowest lung cancer
mortality rate of all states. This fact explains why the lung cancer ranking
for the combined races in DC is closer to the average for the
• DC’s Black males carry the heaviest burden of combined smoking-related cancers. The 5-year incidence rates for these cancers is about 50% higher in DC’s Black males than in the same race/gender group nationally. The rate in DC’s Black women is only slightly higher than rates for Black women nationally. The incidence rates of the other smoking-related cancers in White men and women in DC are slightly lower than the national rates. • In comparison with national Surveillance, Epidemiology and End Results (SEER) data, the incidence rates for smoking-related cancers in DC Black males show a greater excess than do the mortality rates according to data from the North American Association of Central Cancer Registries (NAACCR), suggesting that the high mortality ranking for DC is due to the cancers’ more frequent occurrence rather than poorer survival rates after onset of cancer. The same conclusion can be reached for White males and females but not for Black women. • The incidence rates
for these smoking-related cancers comparing Black and White males within DC
show even greater differences than comparisons with national rates. Rates for • Excesses in risk for
smoking-related cancers in DC’s Black males compared with other race/gender
groups in DC begin as early as ages 35-44. Thereafter, these differences rise
rapidly.
• The risk for various
cancer sites in DC Black males is 2 to 8 times higher than for other • The higher incidence
of smoking-related cancers in DC’s Black population is not attributable to DC’s
urban characteristics. DC rates are higher than rates in
• Mortality rates for the combined smoking-related cancers for Blacks in DC are among the highest in the country, whereas the same rates for Whites are among the lowest—which means there is a huge disparity in rates by race in DC. • Since Black males in
DC are at higher risk than other racial/ethnic groups for smoking- • The rates of smoking-related
cancers are almost twice as high in some wards compared to others. These
differences in risks by ward might suggest some specific areas of DC where
interventions are needed.
Smoking-related cancers in DC Inequality is the most striking feature of
differences in incidence are much greater than the differences in mortality in comparing rates for Blacks and Whites suggests that the major reason for the higher excess mortality in DC in Blacks is the greater frequency of disease in this group. The goal of a smoking-related program for cancer control in DC should aim at reducing this racial disparity. The incidence rates of lung cancer and other smoking cancers by ward or geographic area and gender in DC show major differences (see Table 2). For example, lung cancer rates in males are higher in Wards 1, 4, 5, 6, 7, and 8 than for males in Wards 2 and 3. Lung cancer and other smoking cancer rates are not always highest in the same wards, however, nor do the highest
Survival Survival rates from smoking-related cancers are generally
very poor. The 5-year survival rates from these cancers (except for larynx and
oral cavity cancers) range from 9% to 22%. Even oral cavity and pharyngeal
are amenable to screening (see separate chapter on the subject). The health burden from smoking The health burden from smoking is not The burden from smoking is also borne by individuals who live
or work with smokers Risk factors for lung cancer Several kinds of
occupational and environmental exposure have been associated with the
risk of lung cancer, but the factor that explains 80 to 90% of cases is
cigarette smoking. The risk of lung cancer is reported to be 10 to 20
While direct exposure to tobacco smoke is Other factors that have been associated with a risk of lung
cancer are radon in homes, other environmental radiation, and several
industrial chemicals, such as coke oven gas and metals from chromium refining.
None of these factors should play a major role in lung cancer risk Risk factors for other smoking- For the other smoking-related cancers,
Current smoking levels in DC Historically, Blacks as a race reportedly start smoking later
than Whites and smoke fewer cigarettes, but this pattern may be changing. The reported rate of smoking among The rate for smokers in DC with low education levels is 43%
higher than the overall DC Preventing smoking-related Smoking cessation has been the main focus in reducing
tobacco-related cancers, but the ideal primary prevention strategy is to keep
people of all ages from starting to smoke in the first place—because tobacco is
one of the most addictive drugs. Of course, to stop smoking at any age will in
the long run reduce the risk of smoking-related cancers. The Secondary prevention through screening or early detection is important only for oral cavity
cancers. For the other smoking-related
Aims of a DC smoking program for Any anti-smoking program in DC should aim to do four things: • Prevent the initiation of smoking. • Reduce the number of current smokers • Decrease exposures to secondhand smoke • Reduce the racial
disparity in smoking- Each of these aims will demand programs with slightly
different emphasis but the programs should overlap as part of an integrated
community-based plan that includes all five objectives below. Each objective
must be
Funding for tobacco control in DC To date, the
To DC’s credit, the
tobacco excise tax is $1.00 Goals, Objectives, and Strategies
GOAL: Reduce mortality from
smoking-related cancers in the
Objectives and strategies: 1)
Reduce the level of smoking among high school students from 13% to 10% by • Initiate anti-smoking programs and smoking cessation programs in all high schools. Use programs similar to current DC programs and adapt programs used successfully elsewhere. Programs for smoking cessation must be racially and culturally appropriate and should involve both schools and other points of contact (such as youth centers, family planning clinics, pregnancy clinics, and maternal and child health clinics that see youths under 20). • Consider new approaches to reaching young smokers, possibly using a “cluster” approach that engages youths’ parents and peers. • Consider an increase in the cigarette excise tax in 2007. 2)
Reduce the level of smoking in current Black and Hispanic smokers and those • Establish a smoking cessation quit line for DC youth and adults that will address the needs of a multilingual and culturally diverse population. Include counseling and pharmacotherapy components. • Target promotion of the cessation quit line to
specific racial, ethnic, and geographic • Launch a targeted media blitz against smoking. • Educate professionals
about their importance and effectiveness in persuading smokers 3)
Reduce general exposure to secondhand smoke by creating a smoke-free • Advocate for legislation that bans smoking in all public places. 4)
Reduce racial disparities in smoking prevalence.
• The minimum objective
for DC—a thread running through the previous three objectives—should be to
ensure that DC meets tobacco goals for Healthy People 2010 (Reduce
References Barnoya J, Glantz S.
Association of the
Chao A, Thun MJ, Henley
SJ, Jacobs EJ, McCullough ML, Calle EE. Cigarette smoking, use of other tobacco
products and Dragnev KH, Stover D,
Dmitrovsky E; American College of Chest Physicians. Lung cancer prevention: the
guidelines. Chest 2003;123(1 Suppl):60S-71S.
Ginsberg RJ, Vokes EE,
Rosenzweig K. Non-small cell lung cancer, in Cancer, Principles and Practice of Oncology, eds DeVita VT Jr, Hellman S, Rosenberg SA, 6th
ed, 2001, pp925-983, Lippincott, Philadelphia.
Green PM,
Heloma A, Nurminen M,
Reijula K, Rantanen J. Smoking prevalence, smoking-related lung diseases, and
national tobacco control legislation. Chest 2004;126:1825-1831.
Leistikow B. Lung cancer
rates as an index of tobacco smoke exposures: validation against black male
approximate non-lung cancer death rates, 1969-2000. Prev Med 2004;38:511-515
Mattson ME, Pollack ES,
Cullen JW. What are the odds that smoking will kill you? Am J Public Health 1987;77:425.
O’Brien K, Cokkinides V,
Jemal A, Cardinez CJ, Murray T, Samuels A, Ward E, Thun MJ. Cancer statistics
for Hispanics, 2003. CA Cancer J Clin. 2003;53:208-226
Seltzer V. Smoking as a
risk factor in the health of women. Int J Gynaecol
Obstet. 2003;82:393-397.
Head and Neck Cancers
Facts in brief
• Black males with oral cancers have only half the chance White males have of surviving for 5 years. The poorer survival rates of Black males are partly due to their cancers being diagnosed at a more advanced stage than those of White males. • Incidence rates of cancer at each site in the oral cavity are low but the combined rates represent about 40% of all other smoking-related cancers, except lung cancer, in Black males. The higher rates of cancer in Black males appear to be concentrated in lesions of the tongue, the floor of the mouth, the oropharynx, and the hypopharynx. Lesions at many of these sites would be visible on direct examination of the oral cavity. • The age-specific rates
of oral cavity cancers are higher in Black males beginning at ages 35–44, and
the rates for Black males increase more rapidly than for other race and gender
groups. The rates peak at ages 55–64, when oral cavity cancers are 2.5 times
more likely • Ward 3 has the lowest rate for oral cavity cancers in males. The range of rates by ward differs 4.6-fold. Some of the variation is due to differences in racial distribution by ward. • Patients with oral
cavity cancers have a better survival rate than patients with smoking-related
cancers at other sites, such as the lung, esophagus, and stomach. However, the
treatment • Patients with a first cancer of
the oral cavity or pharynx have a 15 to 20 % chance of having
Cancers of the head and neck, including Risk factors Smokers have a 3- to 13-fold higher risk of oral cavity and pharynx cancers than nonsmokers.
Other factors, such as the use of smokeless tobacco products, also play a role in oral cavity cancers. Data are not available on adult use of smokeless tobacco in DC. According to national data for 2003, 5% of high school students in DC use smokeless tobacco. Risks for oral cavity cancers double in heavy drinkers,
compared with those who abstain from alcohol or are light drinkers. Moreover,
studies suggest that combined exposures to smoking and heavy drinking in the
population may increase the risk of oral cancer to higher levels than the added
risks from each Differences in diet are thought to influence the risk of oral
cancers. In fact, Chinese people from certain areas of
Preventing oral cancers Because oral cavity cancers are related both to cigarette
smoking and smokeless tobacco products, campaigns encouraging people never to
use the products and programs Oral cancer patients have a 15% risk of
Two factors—the high probability of second cancers and a risk
for combined exposures that is greater than additive—strengthen the impact of
reducing smoking. Where there is Early detection is particularly important in Secondary prevention would include a
Dentists may perform oral cavity screening routinely but older populations often do not use routine dental services so it is important to train physicians to perform the screening—especially for the elderly, who often see medical doctors for chronic health problems. Physicians may also need to be reminded of the high risk of second primaries of the oral cavity or pharynx in patients with an original primary cancer of the aerodigestive tract. Freestanding oral cancer screening programs are often underused. Primary prevention programs for smoking cessation can be added to these screening programs to enhance their effectiveness. Screening programs might be targeted at high-risk populations such as men in jails and halfway houses and other sites with many high-risk occupants who have had little contact with medical or dental services before living in such group facilities. Signs and symptoms of head and The most common symptoms of head and neck cancer are listed below. Usually, only one sign or symptom is present. • An ulcer or sore area in the head or neck that does not heal within a few weeks • Difficulty in
swallowing, or pain when • Trouble with breathing
or speaking, such • A swelling or lump in the mouth or neck • Pain in the face or upper jaw. Goals, Objectives, and
Strategies
GOAL 1: Reduce the mortality rate in DC from cancers of the head and neck by 10%. GOAL 2: Reduce the incidence of
invasive cancers of the head and neck in
DC Objective: Increase to 50% the proportion of head and neck cancers detected at the local stage for both men and women by 2010. Strategies:
• Educate dentists, physicians, and other health care providers about screening all patients, especially those who smoke, for early signs of head and neck cancer.
• Through community, church-based,
and work-based programs inform people about the
References Castigliano SG. Influence
of continued smoking on the incidence on second primary cancers involving mouth,
pharynx, and larynx. J Am Dent Assoc 1968; 77:580-585.
De Stefani E, Correa P,
Oreggia F, Leiva J, Rivero S, Fernandez G, Deneo-Pellegrini H, Zavala D,
Fontham E. Risk factors for laryngeal cancer. Cancer 1987;60:3087.
Gerson SJ. Oral cancer Crit Rev Oral Biol Med. 1990; 1:153-166.
Hunter KD, Parkinson EK,
Harrison PR. Profiling early head and neck cancer. Nat Rev Cancer. 2005;5:
127-135.
Licciardello JT, Spitz
MR, Hong WK. Multiple primary cancer in patients with cancer of the head and
neck: second cancer of the head and neck, esophagus and lung. Int J Radiat Oncol Biol Phys 1989;17-467-476.
McGuirt W, Matthews B,
Koufman J. Multiple simultaneous tumors in patients with head and neck cancer:
a prospective, sequential panendoscopic study. Cancer 1982;50;1195-1199.
Morton RP, Hay KD, Macann
A. On completion of curative treatment of head and neck cancer: why follow up? Curr Opin Otolaryngol Head Neck Surg. 2004;12:142-146.
Russo A, Crosignani P,
Berrino F. Tobacco smoking, alcohol drinking and dietary factors as
determinants of new primaries among male laryngeal cancer patients: a
case-cohort study. Tumori 1996;82:519-525.
Sudbo J, Samuelsson R,
Risberg B, Heistein S, et al. Risk markers of oral cancer in clinically normal
mucosa as an aid in smoking cessation counseling. J Clin Oncol. 2005;
23:1927-1933.
Breast Cancer
Facts in brief
• Almost 80% of breast cancers are diagnosed in women aged 50 and older. More than half of breast cancers are diagnosed in women aged 65 and older. Women 65 and older have a significantly higher mortality rate (148.9) than women 64 and younger (19.8). • Roughly 80% of women diagnosed with breast cancer have no known risk factors.
• Nationally, White women have the highest incidence rate (140.8. cases per 100,000 women), followed by Black women (121.7), Asian/Pacific Islander women (97.2), and Hispanic women (89.8). • However, Black women have the highest mortality rate nationally (35.9 deaths per 100,000 women), followed by White women (27.2), Hispanic women (17.9), and Asian/Pacific Islander women (12.5). • Between 1992 and 2000 the incidence rate for Black women remained the same. However, Black women were more likely than White women to be diagnosed with large tumors (larger than 5.0cm). • White women have a higher incidence of breast cancer after age 42; Black women have a slightly higher incidence rate before age 42. • Incidence rates have
remained relatively stable, increasing only 0.4% from 1987 to 2000. • About 10% of women who are carriers of the BRCA1 or BRCA2 gene develop breast cancer. • The District has the highest breast cancer mortality rate in the country (at 37.3 per 100,000 women). • In 2005 an estimated
520 women in the District will be diagnosed with breast cancer and • The incidence rate in
DC (143.3), the fifth highest among all states, is considerably higher • Men can get breast cancer, but male breast cancer is rare (1,300 cases per year).
Breast cancer is the most
frequently diagnosed cancer among District women and the second most frequently
diagnosed cancer among all District residents. The incidence rate is highest in
Ward 2 (224.3 per 100,000 women), The mortality rate from breast cancer is the third highest cancer mortality rate in the District. Ward 2 has the highest breast cancer mortality rate (48.8), followed by Ward 5 (41.7), as Table 2 shows. Research has documented treatment
younger than 45, also develop more aggressive tumors than White women. Those aggressive tumors are difficult to treat and often present at a late stage. Mutations in the p53 tumor suppressor gene, which are associated with poorer outcomes, are more likely to occur in Black women and might make chemotherapy treatment less effective. Risk factors Modifiable risks Alcohol. Studies have shown the risk of breast cancer to increase slightly with increased alcohol consumption. Diet and obesity. Many cohort studies have found that obesity increases the risk of postmenopausal women developing breast cancer. Hormonal therapy. Studies suggest that
reproductive hormones promote the growth Nonmodifiable risks
Family history of breast cancer. Only 10% of
women who develop breast cancer are genetically Hormonal history. Women with an early Childbirth history. Women who experience more pregnancies are at decreased risk, and women who bore their first child when they were 20 years old or younger have about half the risk of women who completed their first full-term pregnancy at age 30 and over. Women who never have children or have their first child after age 30 are at slightly increased risk.
Sexual orientation. When cultural Ways to reduce the Certain actions may lower (but not eliminate) women’s risk of
developing breast cancer. Lifestyle changes that may help reduce women’s risk
of developing breast • Nearly 30% of women 18 and older report engaging in no physical activity. • More than half of adult women in the District, and 68% of Black women, are considered overweight (with a body mass index greater than 25.0). Rates of obesity continue to increase. • DC residents with only
a high school Research has shown that tamoxifen and other agents can reduce the risk of breast cancer in women who are at high risk for developing the disease, and the risk of recurrence in women who have already had breast cancer. These agents do have side effects. Prophylactic mastectomy is an option
The procedure can reduce the risk by 90% in women who are at
moderate to high risk. However, this is a drastic procedure and should be considered
very carefully. It is often regarded as an important option for women who carry
the BRCA1 or BRCA2 genes or who are at very high risk for breast cancer Ways to reduce deaths from Screening and early detection. There has been
a modest decline in deaths from breast cancer, which has been attributed to
successful screening programs and improvements in treatment. Mammography, an
X-ray of the breast, detects about 90% of breast cancers in women without
symptoms. Often these cancers are too small for health care providers
to 80% of women. Mammography testing is more accurate in postmenopausal than in premenopausal women. The breast tissue in younger women is denser than that in post-menopausal women, making it more difficult for mammography to detect breast cancer. Women diagnosed with breast cancer at an early stage, when the tumor is confined to the breast (localized), have a 97% chance of surviving 5 years; when the cancer has spread to the region around the breast, 78%; and when the cancer has spread to other organs, 23%. Table 3 shows data on stage of cancer at diagnosis in District wards. Although some recent studies have cast doubt on the value of
mammography screenings, both the National Cancer Institute and the American
Cancer Society firmly support the value of mammography as a means of • Women get yearly
mammograms starting
• Clinical breast exam
(CBE) be part of a • Women know how their
breasts normally • Women at increased
risk (through family According to the Behavioral Risk Factor
More Black women (72%) are receiving In 2004, the Delmarva Foundation, a quality improvement organization, reported that only 51% of Black women on Medicare (age 65+ and/or disabled) are being screened for breast cancer, compared with 61% nationwide. Diagnosis. If a palpable mass is present or a
mammogram reveals a suspicious lesion, a Treatment. Breast cancer is commonly treated
by a combination of surgery, radiation therapy, chemotherapy, and hormone
therapy. Surgery is still the first line of treatment, but researchers have
found that less extensive, more conservative surgery is just as effective as
radical surgery. Now surgeons may remove Selection of therapy is influenced by age, menopausal status,
stage of disease, the
in terms of estrogen and progesterone, among other factors. The earlier the breast cancer is diagnosed, the more treatment options women have. Barriers to reducing the breast Women’s knowledge, attitudes, and Socioeconomic barriers. Age, poverty, and isolation make it difficult for many women in the District to get either primary care or cancer care. In a city with a high cost of living, 36% of residents are at 200% of the federal poverty level or below. For 30% to 40% of minorities, cost is the reason women report failing to follow up on their physicians’ recommendations. Women also have trouble getting time off from work and finding adequate transportation and child care. English is not the primary language for about 17% of DC residents, and access to language interpreters is limited. Poor literacy, including poor health literacy, makes it difficult for many patients to understand and follow instructions from the doctor or the pharmacy. Cultural issues between patients and health care providers. Minority and immigrant residents report they do not sense an understanding or respect from physicians who do not share their racial and ethnic heritage. Lack of access to health care providers and screening. The waiting time for a
a long time to be seen is discouraging. There are too few mammography facilities, especially in areas
that serve the poor.
There are insufficient public screening and treatment
resources for the medically It is unknown what percentage of women eligible for Project
WISH in DC are served. Nationwide Breast and Cervical Early Fragmented health care system. In DC, Difficulty navigating
the health care
instructions from the health care provider and following through on the instructions) can be overwhelming to a person. Especially if a woman faces any of the additional barriers mentioned above, she may not pursue the screening or medical appointment. Lack of access to
rehabilitation and
Goals, Objectives, and
Strategies
GOAL: Reduce mortality rates from breast cancer in the District by 10%, especially among Black women. Objectives: 1)
Reduce the incidence of invasive disease in DC by 10% by 2010.
2)
Increase the number of women aged 50 through 64 who are screened annually 3) Reduce the proportion of unstaged
cases to less than 5% by 2010.
Strategies targeted to women: • Partner with community organizations and local
breast cancer organizations to bring tailored messages about breast cancer
screening to all medically underserved Black women and to women 50 years old
and older. Encourage such groups to enlist the help of influential public
figures from whom such messages might be more persuasive. Tailored messages
should • Partner with local Centers for Medicare and
Medicaid (CMS), AARP, senior service • Make information about resources for breast cancer screening, treatment, and support readily available to women. Strategies involving system-wide change or activities: • Advocate for sufficient city funding for Project
WISH to supplement federal funding, so that • Subcontract additional components of Project WISH if management and budgeting for the program are inadequate or unstable. • Develop a system that coordinates and connects community health centers with hospitals to ensure continuity of care regardless of patients’ insurance or payor status. • Implement a patient navigation system in DC to
help women connect with appropriate • Expand the mobile mammography screening program, especially for Black women. Such a program could also screen for hypertension, cholesterol, and other diseases. Strategies targeting health care providers: • Ensure that all appropriate health
care providers know about breast cancer screening • Ensure that all appropriate health
care providers are trained to provide clinical breast • Make a family history of breast cancer a required part of every woman’s medical record. • Encourage physicians to set up effective reminder systems for annual screening of female patients. • Make
screening a part of annual physical examinations for all women 50 years old and
older.
References Agency for Healthcare
Research and Quality. Diffusion and Dissemination of Evidence-based Cancer
Control Interventions. Breast Cancer Facts
and Figures 2003-2004. American
Cancer Society.
Centers for Disease
Control and Prevention. Studies on Improving the Use of Breast, Cervical and
Colorectal Screening. Guide to Community Preventive Services. Available at http://www.thecommunityguide.org/cancer/screening.
Accessed April 15, 2005.
Champion VL, Skinner CS,
Menon U, Seshadri R,
D.C. Literacy
Clearinghouse. Literacy Statistics. Available at http://dclearns.org/clearinghouse/stats.
Accessed May 16, 2005.
Love SM, Lindsey K. Dr. Susan Love’s Breast Book. 3rd ed. Perseus Publishing, 2000.
Mandelblatt JS and
Yabroff KR. Effectiveness of interventions designed to increase mammography
use: A meta-analysis of Susan G. Komen. (2005). Breast Cancer Needs Assessment of the National Capital Area.
Gynecologic Cancers
Facts in brief:
• Death from one
gynecologic cancer—cervical cancer—is avoidable. Since the
• DC has the highest
rate of cervical cancer in the
• Endometrial (uterine) cancer is often a curable disease. In 95% of cases there is vaginal bleeding. Women should be alerted to recognize bleeding after menopause as an early warning sign that could lead to earlier diagnosis and the greater likelihood of a cure. • Late diagnosis is also the main
reason for the high mortality rate from ovarian cancer, and there are only
subtle early symptoms and warning signs that women and health care providers
can watch for. In the absence of a screening test, awareness of the disease’s
symptoms may help women seek medical care earlier in this cancer’s progress.
A single intervention could reduce deaths
CERVICAL CANCER
In the diagnosis and treatment of cervical cancer, regular use of Pap smear screening is critical because precancerous changes can be detected and readily treated. Pap smear screening rates have increased dramatically in the past two decades; well over 80% of women surveyed nationally reported having had a recent Pap test. Screening
rates in the District are on a par with the rest of the country, with 89.4% of
DC women reporting having had a Pap smear in
The past 3 years and 94% reporting they ever had a Pap smear. Despite these high rates, there has been a worrisome decline in the proportion of women reporting a recent Pap smear (see Figure 2). There is some indication that this trend reflects an influx of Latinas, many of whom are emigrating from countries with very high rates of cervical cancer and poor access to screening. Almost all women with cervical cancer are infected with human
papillomavirus (HPV), which is the main cause of this cancer. (Note, however,
that although infection with HPV is apparently necessary for cervical cancer to
develop, most women infected with HPV clear the infection spontaneously and do
not
cases have been interpreted as failure to detect existing
precancerous or cancerous lesions, and between 4% and 30% of cases failed to
receive timely, or any, Risk factors for cervical cancer Studies show that several factors increase the risk of
cervical cancer. Risky behaviors exert their influence through their effects on
the risk of acquiring or maintaining specific strains of infection with human
papillomavirus (HPV). Women who are sexually active at an early age, or have
multiple sexual partners, are at greater risk of infection. Women who acquire
HPV are at greater risk of having that infection In a study
characterizing HPV infection among DC women,
fourth leading cause of death from cancer in Latinas in the
Screening for cervical cancer Screening for cervical cancer is recommended starting within
the first three to five years after the onset of sexual activity or by age 21.
After two or three negative annual Pap smears, screening is recommended every
two or three years. The American Cancer Society and
The most important reason that women
present with cervical cancer that has already spread or die from this disease
is failure to obtain a regular Pap smear. Roughly half of the
cervical cancers detected nationally are in women who have never been screened
and 10% are in women who haven’t been screened within the last five years. For
Pap smear screening to lead to early detection of precursors of cervical cancer
or invasive Nationally, the main reasons women don’t The risk of dying from cervical cancer is
Variations in sensitivity of Pap tests
Follow-up after screening Black women self-reported comparable or higher rates of Pap
smear use than Whites starting in the 1980s, but rates of incomplete diagnostic
follow-up and initial Treatment for cervical cancer Women diagnosed before cervical cancer spreads have a dramatically better chance of survival. Two other factors can influence stage-specific survival: the histological (cell) type of cancer and the treatment prescribed. In general, there are two main types of cervical cancer: squamous cell and glandular (adenocarcinoma). In the few studies conducted, there appears to be no difference in histological type in cancers in the DC (compared with
the
Reaching women and preventing deaths Invasive cervical cancer is a preventable Research
indicates that efforts to reduce HPV prevalence, increase screening rates or
Pap test sensitivity, or improve compliance with follow-up will all yield
significant reductions in cervical cancer incidence and mortality. So will
improved treatment. Interventions to increase Pap smear screenings vary
tremendously
quality, and treatment are largely unmeasured in the
District, it is difficult to select a single “best” cancer control strategy.
Interventions that have proven effective elsewhere include mailed or telephone
reminders to get a Pap smear (which increased Pap smear use by up to 18.8%),
using a culturally appropriate lay health worker (which increased use by
18.0%), and offering same-day screening using a nurse-practitioner (which
increased screening by 32.7%). Various interventions should be tested and
evaluated for effectiveness with Newer interventions in development may have future applications in DC. For instance, vaccines to prevent infection in women with HPV 16 and 18 are expected to become available in the near future. Immunization would need to occur before the onset of sexual activity. Data on the efficacy of HPV vaccines in males are not yet available. The first clinical trials have shown 100% effectiveness, so this technology is promising.
ENDOMETRIAL Endometrial cancer, which develops from the endometrium, the
inner lining of the uterus, is the fourth most common cancer in women, after
lung, breast, and colon cancer. In 2005 about 40,000 women nationwide will be
diagnosed with endometrial cancer; about 7,300 are expected to die of the
disease. About 70% of all cases of endometrial cancer occurs in women aged 45
to 74; After increasing from 1988 to 1998, incidence rates of endometrial cancer leveled off through 2001. The 5-year relative survival rate is 85%, and when this cancer is diagnosed at an early stage—as is the case for most
women—the 5-year survival rate increases to 96%. Burden of endometrial cancer in In 2002, 84 women were diagnosed with Endometrial cancer mortality rates in DC increased slightly
from 1978-2002 but have remained stable in the period 1998-2002. Mortality
rates in the District for Black women are higher than those for White women, Risk factors for endometrial cancer According to a recent publication for • Not ovulating regularly and often missing menstrual periods • Beginning menstruation before age 12 • A history of
infertility or never having • Experiencing menopause late in life
• Use of tamoxifen, an anti-estrogen drug used to treat women with breast cancer • Obesity and/or diabetes • A high-fat diet • Family history, especially for women with the inherited tendency to develop a type of colon cancer called hereditary nonpolyposis colon cancer (HNPCC) • Endometrial
hyperplasia (abnormal • Breast or ovarian cancer • Prior pelvic radiation therapy. It’s important to understand that only a small percentage of women who have only one of these risk factors will develop endometrial cancer. Interventions to decrease the Prevention. Most cases of endometrial cancer cannot be prevented. However, these steps can help lower risk: • Use of oral
contraceptives. Taking these • Controlling obesity and diabetes • Eating a diet high in fruits, vegetables and whole grains • Regular exercise. Screening and early detection. At present there is no early detection test or
examination recommended for women without symptoms who are at average risk for this
disease. The American Cancer Society recommends that at the time of menopause,
women should be made aware about the signs and symptoms of this cancer,
especially the importance of seeking immediate treatment for any vaginal
bleeding. About 90% of women with endometrial
cancer develop vaginal
bleeding or discharge that generally leads to early diagnosis. The Pap test for
cervical cancer does not detect gynecologic cancers other than cervical cancer.
Treatment. Treatment for endometrial cancer depends
on the type and stage of the cancer Follow-up. After treatment for endometrial
cancer is complete, monitoring for recurrence should include pelvic
examinations every three to four months for two or three years, and Barriers to care for endometrial cancer Barriers include: • The absence of a screening test • Unawareness of the fact that vaginal bleeding or discharge is an early and important • Limited access to
specialists, which may mean that initial surgery for this cancer may not
produce the careful staging of the
• Delays in treatment, inadequate monitoring of the disease during and after treatment, and inadequate support for side effects from treatment because patients are uninsured or underinsured (a recurrent theme).
OVARIAN CANCER
Ovarian cancer is the deadliest of gynecologic cancers,
accounting for more deaths than any other cancer of the female reproductive
system. This cancer, for which there is presently no screening test for the
general population, is the fifth most commonly diagnosed cancer among women,
ranking second among gynecologic cancers. During 1995-2001, the incidence of ovarian cancer declined at
a rate of 0.8% a year, with rates declining fastest in women 65 or older. The
incidence of ovarian cancer is 18.1 for Whites (per 100,000 women, age-adjusted
to the 2000
In 1995-2000, about 78% of women with ovarian cancer survived
one year after diagnosis and, according to the American Cancer Society, the
overall 5-year survival rate is 44%. For women diagnosed and treated
before the cancer has spread outside the ovary, the 5-year survival rate is 90 to 95%. But only 21% of ovarian cancers are found at this early, localized stage. Burden of ovarian cancer in In 2002, the latest data available from the DC Cancer Registry reported that 41 women in the District developed ovarian cancer (see Table 1), and 32 died of the disease. The disease has a very high rate of recurrence, especially for the great majority of women who are diagnosed with cancer that has spread beyond the ovary. Women in recurrence often undergo years of treatment before a majority succumb to the disease. Impact of disease stage. Statistics for 1997-2001 show that 58% of Black women diagnosed with ovarian cancer in DC have advanced disease (regional or distant metastases), compared with 45% of White women. Early-stage diagnosis is a strong predictor of treatment success for all women with ovarian cancer. It is worth noting
is that in the District, 24% of Black women and 28% of White women are reported
as having “unknown” staging. This suggests either pervasive reporting problems
Risk factors for ovarian cancer Age. The risk of ovarian cancer increases with age, especially at or after menopause. About 50% of all ovarian cancers are found in women over 63. A family history of ovarian cancer. Women with
a family history of ovarian cancer have a Infertility or history of no childbearing. Some research shows that prolonged use of the fertility drug clomiphene
citrate, especially without achieving pregnancy, may increase risk for
developing ovarian cancer. Also, women who have had no children or who had
their first child after age 30 or experienced Use of estrogen replacement therapy and hormone replacement therapy. Recent information suggests that using estrogen replacement therapy (ERT) increases the risk of developing ovarian cancer, and that the risk increases with continued use. The risk among women who used ERT longer than 10 years was almost double
that of women who had never used it, and the risk tripled
among those who used it for 20 years or more.
Interventions to decrease the burden Prevention. There is no proven way to Increased awareness of symptoms. Screening. There is no reliable screening
method for ovarian cancer at present. Development of better screening tests. Treatment. Treatment for ovarian cancer is
generally predicated on the stage of the disease but almost always involves
surgery and chemotherapy. The kind of surgery Support Access to support during and after treatment is important to
women with ovarian cancer, as many cancers recur and women may need support,
information, and assistance for years beyond initial diagnosis. Some DC area
cancer centers—notably
Initial ovarian cancer treatment, including surgery and chemotherapy, often lasts for almost a year, and many women achieving remission will require months beyond the end of treatment to achieve their former energy levels and the abatement of chemotherapy’s side effects. Moreover, recurrence rates are high, and women facing recurrence also face difficult chemotherapy regimens and perhaps additional surgery. Women who are well supported by family, friends, and compassionate employers face a less challenging time than those who are not. Most ovarian cancer chemotherapy can be given at physicians’
offices, at cancer centers and other hospitals, and, in rare instances, at
clinics. Many of the hospitals treating gynecologic cancers are located in
Wards 1, 2, 3, and 4 (Howard, George Washington,
Barriers to care for ovarian cancer There are several barriers to adequate care of ovarian cancer patients, apart from the fact that there is no reliable screening tool for ovarian cancer. Barriers include: Not recognizing warning signs and Delayed diagnosis. Some medical Not infrequently women diagnosed with ovarian cancer complain
of long waits and of needing to see multiple Limited access to specialists. Surgery is sometimes performed on women with ovarian cancer by doctors with no specialized training in gynecologic oncology. This results in less-than-optimal surgery and inadequate screening, which may yield inadequate treatment throughout the course of the disease. Inadequate treatment. For women who are
uninsured or underinsured, the District’s clinics and Medicaid may offer the
only avenue for getting treatment for ovarian cancer. There is no research
documenting these problems
Goals, Objectives, and
Strategies
GOAL 1: Identify a greater proportion of cervical cancer cases before the cancer has spread beyond the local stage. Objectives and strategies: 1)
Increase the proportion of women diagnosed at the local stage to 90% by 2010.
• Conduct a retrospective review of invasive cases to identify missed opportunities or problems with the quality of care. • Focus resources on identifying and screening women 30+ who have never had Pap smears. 2)
Increase the rate of Pap screening to 90% (recent screens) and 97%
(ever-screened) • Survey women to assess knowledge, attitudes, and
behaviors and to address barriers to • Target outreach to Latinas and Asian women, based on survey data. • Target outreach to oldest women and women who have never been screened. GOAL 2: Make 50% of women aware that postmenstrual bleeding is a possible symptom of endometrial cancer by 2010. • Evaluate the feasibility of public education about (and ascertain level of knowledge about) endometrial cancer symptoms. • Develop a public education campaign. GOAL 3: Increase public awareness of ovarian cancer symptoms. 1)
Reduce the incidence of late-stage diagnosis by 2010.
• Conduct a public education campaign in the District, especially targeted to high-risk women. - Develop culturally appropriate information, materials, and training for health care clinics. - Develop information, materials, and training for senior citizen centers. - Develop information for distribution to health care providers. 2)
Improve the amount of accurate staging of ovarian cancer and reduce the • Develop physician awareness programs to make community-based primary care physicians, gynecologists, and surgeons aware of the need for appropriate use of gynecologic oncologists.
GOAL 4: Improve the quality of
care for underinsured and uninsured women in the 1)
Increase information and support to DC clinics and providers treating the
target • Implement a patient navigation system in clinics for women with gynecologic cancers. • Implement a targeted information campaign to make women eligible for Medicaid benefits aware of and use community services and resources. • Provide continuing professional education for providers operating in District health care clinics. • Encourage gynecologic cancer advocacy groups in the community to provide education and program support in District clinics and cancer centers. With thanks to Robin Yabroff, PhD, for
use of data from prior publications.
References for cervical cancer Centers for Disease
Control and Prevention. Strategies for providing follow-up and treatment
services in the National Breast and Cervical Cancer Early Detection
Program--United States, 1997. JAMA 1998; 279(24):1941-1942.
Hildesheim A, Gravitt PE,
Schiffman MH, Kurman RJ, Barnes WA, Jones S et al. Determinants of genital
human papillomavirus infection in low-income women in Washington, D.C. Sex Transm Dis 1993; 20(5):279-285.
Mandelblatt J, Andrews H,
Kerner J, Zauber A, Burnett W. Determinants of late stage diagnosis of breast
and cervical cancer: Mandelblatt JS, Lawrence
WF, Womack SM, Jacobsen D, Yi B, Hwang Y-T et al. Benefits and costs of using
HPV testing to Mitchell JB, McCormack
LA. Time trends in late-stage diagnosis of cervical cancer. Differences by
race/ethnicity and income. Nanda K, McCrory DC,
Myers ER, Bastian LA, Hasselblad V, Hickey JD et al. Accuracy of the
Papanicolaou test in screening for and follow-up of cervical cytologic
abnormalities: A systematic review. Ann Intern Med 2000; 132(10):810-819.
NCI USDHHS.
SEER—Epidemiology and End Results.
Sawaya GF, Brown AD,
Schiffman MH. New
epidemiology of human papillomavirus infection and cervical neoplasia. J Natl Cancer Inst 1995; Yabroff KR, Mangan P,
Mandelblatt JS. Effectiveness of interventions to increase Pap smear use. J Am Board Fam Pract 2003.
References for endometrial (uterine) cancer American Cancer Society
(2005). Cancer Facts and
Figures 2005.
Ball, H.G., Blessing,
J.A., Lentz, S.S., et al. (1996) A phase II trial of paclitaxel in patients
with advanced or recurrent Burke, T.W., Mundt, A.J.,
Muggia, F.N. Cancers of the uterine body. In DeVita, V.T., Heilman, S.,
Creutzbeerg, C.L., van
Putter, W.L., Koper, P.C., et al. (2000) Surgery and postoperative radiotherapy
versus surgery alone for patients with stage-1 endometrial carcinoma:
multicentre randomized trial. PORTEC Study Group. Post Operative Radiation
Therapy in Endometrial Carcinoma. Lancet 355 (9213): 1404-11.
Harris, E.R., Wei, S.J.,
Lentz, SS. (1994)
Advanced and recurrent endometrial carcinoma: hormonal therapy. Semin Oncol 21 (1): 100-6.
PDQ Database. Endometrial
cancer.
Rahaman, J., Cohen, C.J.,
Endometrial cancer. In Kufe, D.W., Pollock, R.E., Weichselbaum, R.R., Bast,
R.C. et al, eds. (2003) Cancer Medicine. 6th ed.
References for ovarian cancer Alberts, D.S., Markman,
M., Armstrong, D., et al. (2002) Intraperitoneal therapy for stage III ovarian
cancer: a therapy whose time has come! J Clin Oncol 20 (19),
3944-6.
American Cancer Society
(2005). Cancer Facts and
Figures 2005.
Bookman, M.A. &
Young, R.C. (2000). Principles of chemotherapy in gynecologic cancer. In W.J.
Hoskins, C.A. Perez, R.C. Young (Eds.) (2000) Principles and Practice of Gynecologic Oncology.
Bristow, R.E., Tomacruz,
R.S., Armstrong, D.K., et al. (2002) Survival effect of maximal cytoreductive
surgery for advanced ovarian carcinoma during the platinum era: a
meta-analysis. J Clin Oncol 20 (5), 1248-1259.
Copeland, L.J., Bookman,
M., Trimble, E. et al. (2003) Clinical trials of newer regimens for treating
ovarian cancer: the rationale for Gyncologic Oncology Group Protocol GOB
182-ICON5. Gynecol Oncol 90 (2Pt 2), S1-7.
Goff, B.A., Mandel, L.S.,
Melancon, C.H., Muntz, H.G. (2004) Frequency of symptoms of ovarian cancer in
women presenting Markman, M. (2001).
Intraperitoneal chemotherapy in the management of malignant disease. Expert Rev Anticancer Ther, Miki, Y., Swensen , J.,
Shattuck-Eidens, D., et al. (1994). A strong candidate for the breast and
ovarian cancer susceptibility gene BRCA 1. Science 266 (5182), 66-71.
Ozols, R.F., Bundy, B.N.,
Fowler, J., et al. (1999) Randomized phase III study of cisplatin
(CIS)/paclitaxel (PAC) versus carboplatin (CARBO)/PAC in optimal stage III
epithelial ovarian cancer (OC): a Gynecologic Oncology Group trial (GOG 158). Proceedings of the American Society of Clinical Oncology 18: A-1373, 356a.
Piver, M.S., Goldberg,
J.M., Tsukada, Y. et al. (1996) Characteristics of familial ovarian cancer: a
report of the first 1,000 families in the Gilda Radner Familial Ovarian Cancer
Registry. Eur J Gynaecol
Oncol 17 (3), 169-176.
Colorectal Cancer
Facts in brief:
• The lifetime risk of
developing colorectal cancer for both men and women is 6%. • Since 1985, the
incidence of and mortality rate for colorectal cancer has • Early detection reduces mortality. Most invasive colorectal cancers begin as polyps, and it takes an average 5 to 15 years before polyps become malignant and form invasive cancers. • The cancer is detected at an early stage, when survival rates are better, among only 27% of White men, 25% of White women, 24% of Black men, and 23% of Black women. For all stages combined, the relative 5-year survival rate is 63% for Whites and 53% for Blacks. • Everyone age 50 or over is at risk and should be screened. • If there is to be only one colonoscopy screening in a lifetime, the most effective age to screen is at 60. Data suggest that screening at this age can reduce mortality from colorectal cancer by 70%. It is better to screen once than not at all.
The burden of colorectal cancer in Among
The annual
incidence rate for DC (59.8 cases/
(53.1
cases/100,000). And the rates of colorectal cancer are higher for Blacks than
for Whites in all age groups. In DC, the incidence of colorectal cancer is
highest in Wards 2 and 5 and lowest in Ward 3 (see Table 2). Ward 8, despite
its high level of poverty, has a relatively low number of cases, perhaps
because young people comprise a significant proportion of the ward. For
2005, the estimated number of new cases of colorectal cancer in Washington DC
(340) is greater than the estimated number of lung cancer cases (310)—and the
number of expected deaths from colorectal cancer in DC is 130.
Risk factors Nonmodifiable Risk Factors Advancing age. Age is the most common risk factor for colorectal cancer. The incidence of the disease increases with age, especially after 60. Thus, screening becomes more effective with age. Family history of the disease. Most Modifiable risk factors Colonic or rectal polyps. Nearly all
colorectal Inflammatory bowel disease. Inflammatory Inappropriate diet. Studies suggest that obesity is a risk factor for colorectal cancer. Other factors have been implicated, including low consumption of fiber and high consumption of red meat and fat, but these findings have not been substantiated. Reducing deaths from colorectal cancer The main interventions to reduce deaths from colorectal cancer include prevention, genetic testing (when
appropriate), screening and early detection of precancerous lesions and cancer. Primary prevention Encourage changes in what and how much people eat. Dietary interventions are designed to promote and increase the consumption of foods and nutrients known to reduce the risk of cancer. This means less meat and more fruits, vegetables, and fiber. It also means reducing obesity, a recognized risk factor for colorectal cancer and many other diseases. Encourage more physical activity. There is evidence that regular physical activity may help prevent the onset of many forms of cancer. Genetic testing Encourage genetic testing, when Screening and early detection Screening improves the chances
of early
Four screening tests are in common use:
Sigmoidoscopy. A standard procedure that
examines only the distal or left colon and rectum, the sigmoidoscopy is only
moderately expensive and takes only a short time. Although sigmoidoscopy is
considered effective in reducing deaths from colorectal Colonoscopy. Fiberoptic colonoscopy is
substantial drawbacks as a screening test. It requires highly trained personnel and is expensive and time-consuming. An intravenous catheter is used to administer sedatives, recovery time is one hour, and a second person must accompany the patient home. But colonoscopy is the only procedure that can identify and remove precancerous polyps and detect early cancer. Colonoscopy should be required of everyone in whom cancer is suspected, who has had previous colorectal cancer, or who is at very high risk. Colonoscopy is most effective in preventing cancer if performed between the ages of 56 and 66, when precancerous polyps are most likely to be present. Double contrast barium enema. Often used for surveillance by radiologists, this may be useful in some cases for identifying polyps that are difficult to recognize by colonoscopy. Most often, patients are referred by their physician for this procedure. Follow-up for high-risk patients Repeated screening at specified intervals is recommended for
individuals who are at high risk because of previous polyps, a family Barriers to reducing the cancer burden Screening rates for colorectal cancer remain lower than those for other cancers. Less than
Common barriers as patients see them The public appears not to have been well informed about the
risk of, or the risk factors associated with, colorectal cancer. Despite
widespread publicity about colon cancer, increased reimbursement for screening,
and data from national health surveys, the screening rates for colorectal
cancer are significantly lower than those recorded for breast or cervical
cancer. Common reasons • Practical issues, such as inconvenience • Conflicts with work or family • Lack of insurance or medical coverage • Lack of interest • The tests’ unpleasantness • Anxiety about the results • Lack of access • Lack of awareness about testing • Fear of cancer • The idea that cancer cannot be cured • Age (young patients are less compliant • The physician’s
failure to recommend Barriers among health care providers The key factor in promoting cancer screening is a
physician-patient relationship of trust. no access to screening facilities, lack of trained personnel,
lack of information about screening Barriers in the health care system Economics and limited access are barriers Rules about reimbursement coverage need to be clarified because lack of knowledge or widespread variation in reimbursement rules and application serve only to discourage screening. Screening should be included in health plans offered by both private and government sources, and reimbursement should not be so low as to discourage screening. Insurers should be made aware that routine screening is cost-effective because it prevents costly treatment and hospitalization.
Goals, Objectives, and
Strategies
GOAL 1: Reduce the mortality rate in DC from colorectal cancer by 10%. GOAL 2: Reduce the incidence of invasive disease in DC by 10%.
Objectives: 1) Increase to 50% the proportion of
colorectal cancer detected at the local stage 2) Increase to 50% the proportion of the
adult population that reports having had a 3) Increase to 60% the percentage of
the population age 50 or older screened by
Strategies • Encourage professional
organizations to promote screening among their members. • Develop the
infrastructure to provide screening for all DC residents, whatever their
cultural • Develop community
education and outreach campaigns about common risk factors and • Reduce cultural,
ethnic, and financial barriers to screening by targeting education programs • Encourage athletes, television personalities, politicians, teachers, and other role models to serve as advocates for routine screening (whatever the test). • Increase the number of physicians who recommend screening to patients and who routinely take a family history of cancer. Train physicians to inquire about every patient’s family history of cancer, whatever the purpose of their medical visit, and invite family members to undergo screening or genetic testing if a familial risk pattern exists.
• Encourage physicians to use reminder or other systems for recalling patients for screening. • Make health care
professionals aware of centers in DC for colorectal cancer screening and • Through professional
associations, arrange for scientific presentations, newsletter items, • Encourage at least
once-in-a-lifetime colonoscopy screening at about 60 as a “rite of • Promote better insurance coverage and other forms of assistance for colorectal screening.
References Adams EK, Thorpe KE,
Becker ER, Joski PP, Flome J. (2004). Colorectal cancer screening, 1997-1999:
role of income, insurance and policy. Prevent Med, 38, 551-557.
Dunlop MG. (1992). Screening
for large bowel neoplasms in individuals with a family history of colorectal
cancer. Br J Surg, Lynch HT, Smyrk T.
(1996). Hereditary nonpolyposis colorectal cancer (Lynch syndrome). An updated
review. Cancer, 78, Ramsey SD, Andersen MR,
Etzioni R, Moinpour C, Peacock S, Potosky A, Urban N. O. (2000). Quality of
life in survivors of Rawl SM, Menon U,
Champion VL, Foster IL, Skinner CS. (2000) Colorectal cancer screening beliefs.
Focus groups with Rickert RR, Auerbach O,
Garfinkel L, et al. (1979). Adenomatous lesions of the large bowel: an autopsy
survey. Cancer, 43, Seeff L, Nadel M,
Blackman D, and Pollack LA. (2003). Colorectal Cancer Test Use Among Persons
Aged 50 Years And Seeff LC, Nadel MR,
Klabunde CN, Thompson T, Shapiro JA,
Sirovich BE, Schwartz LM,
Woloshin S. (2003) Screening men for prostate and colorectal cancer in the
Subramanian S, Klosterman
M, Amonkar MM, Hunt TL. (2004). Adherence with colorectal cancer screening
guidelines: a review. Prevent Med, 38,536-550.
Walsh JME, Terdiman JP.
(2003). Colorectal cancer screening. Scientific Review. JAMA 289.1288-1296.
Prostate Cancer
Facts in brief:
• The projected number
of new cases nationally in 2005 is 230,090—with an • Estimates are that 610
men in the District will be diagnosed with prostate cancer • The lifetime risk of
being diagnosed with invasive prostate cancer is 1 in 6. The • DC has the highest mortality rate from prostate cancer in the nation. The rate is twice as high in Black men as in White. Incidence rates for Black men in DC are among the highest in the nation. The incidence and death rates for Black men are highest the world over, according to the International Agency for Cancer Research. The risk is lowest in men of Asian descent. • Nationally, the median age for diagnosis is 66 for Black men and 69 for White men. The median age of death from prostate cancer is 77 for Black men and 79 for White. • On average, 9 years of life are lost to prostate cancer. • The causes of prostate cancer are largely unknown. • Prostate cancer eventually affects nearly all men but is clinically unimportant in most men.
An uneven burden Prostate cancer does not affect everyone equally. Its impact
on Black men is From 1998 through 2002, there were 2,671 new cases of
prostate cancer in the
Incidence and mortality rates (Tables 1 and 2) are highest in Wards 2 and 4. The incidence of prostate cancer in White men began to decline nationally in 1993 and for Black men in 1994. Differences in incidence, clinical stage, and histological (cell) grade are still found in every age group among White and Black men. Prevention Currently, there is no known way to prevent prostate cancer, although the National Cancer Institute is conducting research on prevention. Men are usually advised to avoid or minimize risk factors, but this is not always possible.
Risk factors for prostate cancer Common risk factors include age, race, Age. Age is the strongest risk factor. Prostate cancer is largely a disease of older men; it is rare below the age of 50. The risk increases steadily with age and more than half of all men will have some cancerous growth by the time they are 80, although in most cases it goes unnoticed. Half of all cases are registered in men over 75 and 90% of prostate cancer deaths occur in men 65 and over. Race. Prostate cancer’s devastating effects
men. The mortality rate per 100,000 men was 23.4 for White men and 66.4 for Black. The onset of invasive prostate cancer comes at a younger age
in Black men, and Black men also register premalignant changes earlier. HGPIN
(high-grade prostatic intraepithelial neoplasia), a premalignant lesion that
progresses to invasive cancer, is more prevalent in Black men than in White.
HGPIN was found at autopsy in 18% of Black men in their forties (compared with
14% of White men the same age); in 31% of Black men in their Within a clinical setting, Black men are more likely to present with advanced-stage disease and less differentiated tumors than White men. The reason is unknown. Differences between Black and White men |
Developing
a Cancer Control Plan 
Timing and follow-up are also issues in
health care centers, where it often takes too much time to arrange for
diagnostic follow-up, treatment, and post treatment care. For lack of equipment
and expertise to handle billing adequately, community health centers have at
times had difficulty submitting timely program and financial information to
contractors and health plans. Project WISH, the DC Breast and Cervical Cancer
Early Detection Program, lost funding temporarily because it did not receive
timely reports from community health centers that are Project WISH provider
sites.
There is a growing body of epidemiological
evidence suggesting that factors 
Diets high in fruits, vegetables, and whole
grains reduce the risk of cancer—especially cancers of the colon, esophagus,
lung, and oral cavity. According to the National Cancer Institute’s “Eat 5 to 9
a Day for Better Health” Program, to reduce risk people should consume at least
five to nine servings a day of vegetables and fresh fruits, such as citrus,
yellow and green leafy 
wards necessarily demonstrate the same excesses
for men and women. Ward 3 has the lowest rates for almost all cancers for both
men and women. No single ward has the highest rate for all of the cancers,
despite the fact that these cancers all have smoking as a unifying risk factor.
(All data represent an analysis for a five-year period to stabilize the rates
by ward).
Recent analyses suggest that Pap smears 
half of the
